Patient Registration
Demographic Information
Last Name:
First Name:
MI:
Date of Birth
Sex:
Race:
Ethnicity:
Address 1:
Address 2:
City:
State:
Zip:
Language:
Language Country:
Whom may we thank for referring you to our practice?
Emergency Contact Information
Contact First Name:
Contact Last Name:
Contact Home Phone:
Contact Cell Phone:
Relationship To Patient:
Contact Address:
City:
State:
Zip:
Primary Care/Other Physician
Physician Name:
Practice Name:
Address 1:
Adrdress 2:
City:
State:
Zip:
Insurance Information
Primary Insurance
Insurance Company:
Co-Pay:
Group #:
Subscriber #:
Insured First Name:
Insured Last Name:
MI:
Date of Birth
Social Security #:
Relation to Patient:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Ext:
Where Is It Filed?
Insured Employed By:
Business Address:
City:
State:
Zip:
Business Phone:
Ext:
By signing below, I attest that the information provided above is true and accurate.
Authorization to release or use information for treatment, payment, or health care options.
I hereby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by
in order to carry out treatment, payment, or health care operations. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such notice prior to signing this Consent Form.
We reserve the right to change the terms of its Notice of Privacy Practice at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff.
You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or healthcare operations. Our practice is not required to agree to such requested restrictions; however if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.
I agree and consent to
releasing information to me in the following manners:
Your insurance card and photo ID are tequired at the time of your visit. By signing below, I attest that the information provided above is true and accurate.
Office Policies
Thank you for choosing the "Hana Holistic Medical Center" for your office health care. Our office aims to provide you with excellent medical care and customer service. We have implemented policies that will assist us in achieving our goals which we would like to bring to your attention.
1. New patients please arrive 15 minutes before your appointment time. You must have a valid insurance card and current identification at the time of the first visit.
2. Insurance co-pays are due at the time of service: Patients who do not pay their co-pay are billed a $15.00 service charge in addition to their co-pay. If you have an outstanding balance at the time of your appointment, payment will be expected. We accept cash, checks, and all major credit cards for your convenience. There is a $25.00 service charge for a returned check. Insurances are billed as a courtesy and the patient has financial responsibility for payment in full for services rendered.
3. Insurance coverage and deductibles: We recommend that you check with your insurance company whether we are listed under the network and what's your expected payment. We will collect a $175 deposit for each visit with high deductible plans. You will be refunded or billed for any difference after processing your claim.
4. Appointment and Cancellation policy: We recommend arrival 15 minutes prior to the visit. Late arrivals will be seen only upon the discretion of the provider. We request the courtesy of an advanced notification of 24 business hours for any appointment cancellation or reschedule. If you fail to notify us of your inability to keep your appointment, a "no-show" for your appointment time will be noted in your chart. After two consecutive no-shows, you may be considered for discharge from the practice. All patients who fail to present for their visits or cancel within 24 hours of their appointment will be subject to a fee of $50.00 for the first visit and $25.00 for a follow-up visit.
5. Prescription refills: New prescription and prescription charges are available to you during your visit. Refill requests should be made to your pharmacy, Please do not wait until you are out of medication to request a refill and allow 72 hours for prescription refills.
6. Lab copies: Most of the time, your labs will be available to be seen through the patient portal online. Paper copies of your labs can be requested during your visit as well.
7. Medical records: If another practitioner is requesting your records, they can be sent electronically, faxed, or mailed at no charge after you sign a medical release. Otherwise, to obtain a copy of medical records a fee of cents per page and $6.00 per 15 minutes of processing fee is paid on request and may take up to two weeks. The records can be picked up at the office. Upon request, they may be mailed Certified/return receipt for an additional cost of the mailing fee.
8. Online Communication: As a courtesy to our patients, we respond to your request online through the patient portal. We recommend that the online communication be brief and limited to simple questions and answers. Please allow 24 - 48 hours for a response from our office. For urgent matters, we recommend that you call our office.
9. Phone visits: Communication with the physician through the portal is provided as a courtesy to our patients. Follow up visits on the phone upon the discretion of the provider.
10. After-hour phone calls: We are happy to answer the phone during our regular business hours, which are Monday to Friday, 9:30 am to 5:30 pm and we are closed for lunch between 12:30 pm and 1:30 pm. If you call our office after 5:30 pm or over the weekend, we advise you to leave a message and we will respond to you the next business day. If you have a matter that requires urgent medical attention, we advise that you visit the nearest Emergency Room.
Consents:
Please read carefully, initial next to each statement and sign the form.
1. I have read and received a copy of this practice's Notice of Privacy Practices and the office policies.
2. I give my consent to release medical information to the following parties: Third party payors covering the medical services, other health care professionals, institutions involved in my care, the proponent of any legally sufficient subpoena, or in response to a court order, employees and agents of the practice, pharmacies and other parties as otherwise required by law.
3. I authorize "Hana Holistic Medical Center" to use SureScripts, Inc. a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy.
4. I hereby assign all medical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), to issue payment check(s) directly to "Hana Holistic Medical Center" for the medical services rendered to myself.
5. I give permission for "Hana Holistic Medical Center" to give me medical treatment. I understand that I have the right to discuss all medical treatments with my provider and to refuse any procedure or treatment.
6. I hereby give authorization to release information and/or discuss my medical condition including my protected health information with the person(s)/entities listed below:
Person/entity name:
Phone #
Relationship to Patient
This authorization can be revoked at any time upon my request in writing.
Authorization For Use And/Or Disclosure Of Patient Health Information
I understand that Hana Holistic Medical Center will not condition treatment, payment, enrollment, or elogibility for benefits on my providingor refusing this authorization.
I hereby authorize
to disclose to
Hana Holistic Medical Center
2107 Channing Way, Berkeley, CA 94704
Records and information pertaining to
Duration: The authorization shall become effective immediately and shall remain in effect unless a different date is specified.
Revocation: This authorization is also subject to written revocation by the patient/guardian at any time. The written revocation will be effective upon receipt, except to the extent that the disclosing party or others have acted in reliance upon this authorization.
Redisclosure: I understand that the receipt may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is especially required or permitted by law.
Specify Records: Check and initial to specify which type of information that is to be disclosed.
Specify the records to be disclosed:
The receipt may use the information authorized on this form for the following purposes:
If signed by other than patient, indicate relationship:
Membership Agreement For Patient-Centered Holistic Medicine Services
Member Name:
Mailing Address:
Email:
Primary Phone Number:
Secondary Phone Number:
Date:
*Member signature required in last page.
THIS MEMBERSHIP AGREEMENT FOR PCHM ("Agreement") is effective as of the Effective Date written above, by and between HAH HOLISTIC MEDICAL CENTER, a California medical service ("Provider") and the Member identified above, with reference to the following facts:
WHEREAS, the Patient identified above desires unique services and benefits to be provided by Physician that are not covered or otherwise not reimbursable under a private health insurance policy, private health plan or government program, including, but not limited to, Medicare, in which Patient, is enrolled;
WHEREAS, the Physician identified below desires to provide such unique services and benefits to Patient for which the Physician cannot, and will not, seek reimbursement under a private health insurance policy, private health plan or government program, including, but not limited to Medicare, in which Patient is enrolled;
WHEREFORE, by signing this Patient Enrollment Agreement, Patient and Physician hereby agree, effective on the date signed by Physician, for valuable consideration, to enter into a contractual relationship for the provision of specified services and benefits under the following terms and conditions.
I read the office policies for Hana Holistic Medical Center and I agree to all of them.
A. Benefits and Services
Hana Holistic Medical Center (HHMC) agrees to provide to Patient the following Benefits and Services:
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10% off acupuncture sessions (not covered by Medicare or insurance);
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3 free classes , and 5% off weekend workshops at HHMC; and
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Access to signing up for membership in classes through HHMC information system.
Classes and workshops may include the following which are provided for a free subject to above mentioned discounts:
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Yoga classes;
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Group fitness;
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Dance therapy;
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Tai Chi;
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Chi Gong;
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Energy movement exercises;
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NIA dance;
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acupuncture;
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Energy healing; and
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Massage therapy.
HHMC's goal will be to nurture and support the patient's personal transformation to a healthy wellness-based lifestyle. In keeping the classes in all groups, HHMC visitors will receive a more personal connection with teachers.
HHMC will provide educational workshops which with the goal of enhancing the knowledge and art of healing the body, mind and spirit. These workshops may include lectures and courses about Chinese medicine, acupuncture, healthy eating, herbology, bodywork, and mindfulness-based stress reduction.
As a member of Hana Holistic Medical Center you will have the advantage of our premium MediTouch patient portal where you can have:
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Priority email to your doctor.
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Secure, online access to your personal health record.
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Time saving tools such as easy registration and appointment scheduling as well as request for video visits.
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Access to your lab results and ability to request medication refills online.
B. Premium
Patient agrees to pay to Physician and ANNUAL Enrollment fee of $250 or $25 MONTHLY as valuable consideration for the provision of Benefits and Services or
100 patients will have an option to become "Vision Supporters" of the center for a MONTHLY membership of $199 for unlimit free classes, 10% off weekend workshops and 20% off acupuncture sessions (not covered by Medicare or insurance).
C. Patient Acknolledgements And Conditions Of Participation
Patient acknowledges and understands the Benefits and Services are unique and provided with certain specific limitations and conditions, as follows:
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Benefits and Services are not covered and otherwise not reimbursable under any private health insurance policy, private health plan or government programs, including, but not limited to, Medicare, in which Patient is enrolled. accordingly, Patient understands and acknowledges that Benefits and Services coney value and benefits that Patient does not already receive any private health insurance policy, private health plan or government program, including, but limited to, Medicare, in which Patient is enrolled. To the extent any one or more Benfits and Sevices are considered covered and reimbursable benefits, the Enrollment Fee is considered for the remaining items of Benfits and Services.
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The list of Benefits and Services may be amended or modified to the extent necessary to reflect any changes in interpretation or terms of coverage and benefits of any private health insurance policy, private health plan or government program, including, but not limited to, Medicare, in which Patient is enrolled.
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For Benefits and Services provided herein, Patient and/or Physician cannot, and will not, bill to or seek reimbursement from any private health insurance policy, private health plan or government program, including, but not limited to, medicare, in which Patient is enrolled.
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Physician may also provide service(s) to patient that are covered or reimbursable from a private health insurance policy, private health care plan or government program, including, but not limited to, Medicare, in which Patient is enrolled. In such ace, Physician may bill and seek reimbursement from Patient's private health insurance policy, private health plan and/or Medicare under the terms and conditions of Patient's enrollment agreement with such payor(s). Physician may also seek reimbursement from Patient as permitted under Patient's enrollment agreement with such payor(s) (e.g., deductibles, coinsurance or copays). Patient understands and acknowledges that any covered and reimbursable services are separate and distinct from and independent of the Benefot and Services provided herein.
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This Agreement can be terminated by providing a notice to the Medival center of at least 45 days. We believe the 45 days is necessary to allow the Medical Center to make every effort to accomplish your health golas.
By signing below, I attest that the information provided above is true and accurate.
Contact Information
Home Phone:
Work Phone:
Ext:
Cell Phone:
Email:
Family Members In The Practice
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Pharmacy
Pharmacy Name:
Pharmacy Phone:
Pharmacy Location:
Additional Insurance
Insurance Company:
Co-Pay:
Group #:
Subscriber #:
Insured First Name:
Insured Last Name:
MI:
Date of Birth
Social Security #:
Relation to Patient:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Ext:
Insured Employed By:
Business Address:
City:
State:
Zip:
Business Phone:
Ext:
Employment
Occupation:
Business Name:
Business Phone:
Drivers License#:
State Issued:
IN WITNESS WHEREOF, the parties have executed this Membership Agreement for PCHN Services effective as of the date first written above.
Member:
Provider: Hana Holistic Medical Center
Anas Hana, M.D., President
Your form has been submitted
Date of Accident: